Care Coordination for Dually Eligible Beneficiaries

Care coordination has been identified as a potential method of achieving the triple aim in health care—improving outcomes and care quality while reducing costs. Well-designed, targeted care coordination entails comprehensive coverage of services across a coordinated provider team working together to provide high-quality, patient-centered care. This model, however, faces significant challenges at both the payment and delivery levels. Health care payment is traditionally “silo-based,” with payers reimbursing individual providers for specific services without consideration of other services. The fee-for-service (FFS) model does not incent care coordination among providers and may even serve as a deterrent, because a reduction in utilization resulting from better and more coordinated care would mean a reduction in reimbursement for certain providers. The care coordination challenge extends to health care delivery, where again, coordination is discouraged as it typically requires costly infrastructure investments from providers with no promise of future savings or reimbursement from payers. The care coordination problem is quite evident in the fragmented care received by the sickest and frailest members of society, those who are dually eligible for Medicare and Medicaid (duals). This population is typically dealing with multiple chronic illnesses as well as functional limitations that require long-term care. Because of their health profiles, the duals tend to have multiple providers and require services that are covered by Medicare and Medicaid. Approximately 9,200,000 individuals in the United States are dually eligible for both Medicare and Medicaid coverage. They qualify for Medicaid due to their low income and assets. Roughly sixty percent are elderly duals